Cities

Anthrax, Risk Communication and Crisis Leadership By Howard K. Koh

Until the fall of 2001, I had devoted four years immersed in the demands of a state health commissioner: heading the Massachusetts Department of Public Health (M.D.PH) and overseeing a wide range of health services, four hospitals, and a staff of 3,000 professionals. The work was intense, broad and traditional. Then came 9/11.

As a member of the National Cancer Institute (NCI) Advisory Board, I was in the greater Washington, D.C. area that morning listening to NCI Director Richard Klausner deliver his resignation speech. Halfway through his remarks, an aide interrupted him and whispered some information— after which, he abruptly announced that two planes had just hit the World Trade Center and that the meeting was adjourned. In fact, a third plane had also just struck the Pentagon, only several miles away. And unbeknownst to me, of the total of four planes involved in the attacks, two had departed Boston’s Logan Airport that morning, as I had.

Immediately, the entire country was dazed and reeling. Then, to our utter disbelief, October 5began the next chapter of national suffering marked by the first death from inhalational anthrax. The cases started in Florida but over a matter of weeks snaked up the East Coast to northern Connecticut, just a few miles from outstate borders. It seemed unthinkable and inconceivable that bioterrorism could completely engulf our public health agenda. But this unwelcome intruder disrupted the nation for the rest of the Fall, leaving our daily lives in tumult.

The following weeks were a kaleidoscopic blur of briefings, conference calls, meetings, and press conferences. Our Massachusetts Governor immediately convened daily meetings with our state leaders, many of whom I had never previously met. In particular, I found myself connecting feverishly with officials from public safety, fire, police and even the postal service, many of whom became instant, if not unconventional, partners. As reliable information on both the national and state scenes was always elusive, we scrambled to gather accurate data through any conceivable source. For example, once, while driving to speak at a news conference, I heard New York Mayor Rudy Giuliani on the radio announcing yet another anthrax case in New York City. When I arrived, the first press question posed to me was about the specifics of that new case. There were many moments like that.

Our state laboratory officials, traditionally relegated to obscure work in underfunded and archaic facilities, were suddenly thrust into the media limelight. The laboratory was deluged with samples of white powder sent for anthrax testing. Here was a typical scenario: a jittery and unnerved town resident would discover “suspicious” white powder in his community. Immediate notification of the local police or fire department would trigger both the closing of the local post office and the sudden arrival of HAZMAT teams, bedecked in imposing space- suit paraphernalia. The teams would delicately handle the samples under the watchful eye of local media and news cameras. Then, those samples would be delivered to theM.D.PH state laboratory for analysis. A hastily arranged press conference would feature harried state and local officials trying to explain the unfolding developments to an increasingly anxious public. And when testing in the laboratory subsequently yielded negative results for anthrax, that finding would prompt yet another round of news announcements as well. Multiply this situation by several thousand — and that was the Fall of 2001in our state, and indeed, around the country.

As Commissioner, I was charged with leadingM.D.PH through this time, interacting with other state officials, the press, health professionals, community groups, hospital leaders, advocates, among others. It soon became clear that my primary role was risk communicator- in-chief. The deluge of questions from the press and public alike seemed endless: What is anthrax? Why have we never heard of this before? How many people were infected? How many samples of white powder had been tested? How do I safely open my mail? Should I take antibiotics to protect myself? Is it fair that some people have access to medications while others do not? Would this situation get worse? What if terrorists use smallpox to kill people? Am I safe?

In the midst of this chaos, I understood that each interview had to focus on facts, not speculation. With each press interaction, I shared the information known and promised to share more as soon as it came available. It was important to acknowledge the anxiety without succumbing to it. It was also critical to project some sense of calm, setting an empathetic and compassionate tone. It was difficult to lack ready answers in this constant swirl of uncertainty. But I was honored to emphasize to any audience that thousands of public health professionals had stepped forward in this unprecedented time, working 24/7 on their behalf. In fact, the crisis represented a tremendous opportunity to underscore and reaffirm publicly the fundamental mission of public health: to protect people against threats — known and unknown —in a time of crisis. As a physician who has cared for patients for decades, I had had much experience delivering difficult news to anxious patients. But this situation stretched me beyond anything I had ever previously experienced. I had to leverage every possible skill as a physician, scientist and public official to uphold public trust. And across the country, I saw my other public health colleagues also giving it their all, trying to transform a moment of “no hope” to “new hope”. I was proud of them — we all will forever share a bond.

When it was all over, the nation witnessed 22 anthrax cases and five deaths, none in Massachusetts; but the trauma left millions in its wake. For the remainder of my tenure as Commissioner, we dealt with the aftermath, dramatically realigning budgets to balance fragile public health programs with new preparedness demands. And when I assumed my new positions as Professor and Associate Dean at the Harvard School of Public Health, I also headed their Center for Public Health Preparedness. We focused on preparedness education and training, risk communication, integration of preparedness and prevention, building better information networks, and using drills and exercises to build a more prepared professional workforce. I brought many of those lessons with me in 2009 to the U.S. Department of Health and Human Services where I now serve as Assistant Secretary for Health.

Looking back at the first decade of the 21st century, our public health history now covers many crises previously viewed as unthinkable. In addition to 9/11 and anthrax, this remarkable litany of “low probability, high consequence” events now includes SARS (2003), Hurricane Katrina (2005), the H1N1 pandemic (2009) and the Gulf Coast oil spill (2010), among others. Through each of these episodes, as noted by Mitroff1, we have been subjected to the predictable elements of crisis: invalidation of previous fundamental assumptions, the irrelevance of conventional thinking and conventional responses, rapid escalation of events, moral trial by compelling images in the media and tremendous technical and even ethical uncertainty. Since 9/11, our nation’s ability to coordinate response has certainly grown dramatically. But the next challenge always seems to be just around the corner.

Each new crisis demands renewed leadership. As we seek to train the next generation, we must attract those who are willing and able to step forward and serve at all times and under any circumstance. They must be committed to trying to unify in times of need while acknowledging the unfamiliar and the ambiguous. They must create uncommon bonds among untraditional partners, and mobilize people to want to reach for higher aspirations. This requires not just intelligence and knowledge but also a sense of strategy, personal will and tremendous interpersonal skill. They must be willing to embrace the “public” part of public health, since we practice our craft on an open stage. In the final analysis, each crisis can represent an opportunity to create a renewed sense of community, reminding us yet again that we are all interconnected, all interdependent and we all have promises to keep.

Howard K. Koh, M.D., M.P.H., U.S. Assistant Secretary for Health, U.S. Department of Health and HumanServices, Massachusetts Commissioner of Public Health, Commonwealth of Massachusetts (1997-2003)